RLE 002

Cebu Normal University

College of Nursing
Cebu City
Mission-Vision: Care Using Knowledge and Compassion
Name of Student: __________________________________________
Clients Initials: D.C._________________________________________ Stressor Classi!"ation: #$lease "%e"&'
(ge: )* y.o. +ender: Male Civil Status: Married ,eligion: ,oman Cat%oli" __-___ $%ysiologi"al #body stru"ture and fun"tions'
(llergies: no &no.n food and drug allergy__________________ ______ $sy"%ologi"al #mental /ro"esses and emotion'
Diet: not%ing /er orem___________________________________________ ______ So"io-"ultural #relations%i/s0 so"ial e1/e"tations'
Date of (dmission: _anuary 20 345)_________________________ ______ S/iritual #in6uen"e of s/iritual beliefs'
Diagnosis-Im/ression:_$MS78 /rob. Se" to +I malignan"y and anemia se" to 95 ______ Develo/mental #develo/mental /ro"esses over
t%e lifes/an'
NURSING DIAGNOSIS NURSING GOALS NURSING OUCO!E
(ssessment Diagnosis Mutual $lanning
#+oal attainable .it%in t%e
s%ift'
Interventions
#.it% ,ationale : Sour"e'
("tual
;valuation
S"#$e%&i'e(
<=a/oi /a man
li%o& dai0 luya
/a gamay<0 as
verbali>ed
O#$e%&i'e(
,e"eived lying on
bed?aslee/? .it%
ongoing IV@ of
9) $NSS 5A
BC4gtts-min?
.it% vital signs of
D: CE.C degrees
Celsius0 $: 2E
b/m0 ,: 34"/m0
7$: 5)4-*4
mmFg?
.ea&ness noted)
@atigue related to
imbalan"e bet.een
o1ygen su//ly and
demand
(fter G %ours of
nursing
intervention0 %e
/atient .ill be able
to:
identify basis
of fatigue and
individual
areas of
"ontrol
/erform
a"tivities of
daily living
and
/arti"i/ate in
desired
$,IM(,H IND;,V;NDI8NS
*romo&i'e(
I- identify fa"tors "ausing fatigue of
"lient
,- to &no. nature of interventions to
be given
S- Doenges et. al. 3454
I- identify .it% "lient resting /eriods
and /referen"e
,- to render a//ro/riate s/a"ing of
interventions
S- Doenges et. al. 3454
I- assess vital signs
,- to evaluate 6uid status and
"ardio/ulmonart res/onse to a"tivity
S- Doenges et. al. 3454
I- determine degree of slee/
disturban"es
,- fatigue may be a result to slee/
de/rivation
D%eory-based #Betty Neuman'
NURSING CARE *LAN
(ssessment C /oints +oals 3 /oints Interventions ) /oints 7ibliogra/%y
Diagnosis C /oints D%eoreti"al 7asis 3 /oints ;valuation 5 /oint +, poin&s
/t. de/endent on
S8 for feeding
and bed mobility?
lo. %emoglobin
and %emato"rit
"ount #Fgb: I4
and F"t: 5G as of
@ebruary E0 345)'
-eore&i%al #asis(
Fatigue: An overwhelming
sustained sense of
exhaustion and decreased
capacity for physical and
mental work at usual level.
Doenges et. al. !"!
#he patient$s current
hospitali%ation and
constant interaction with
the healthcare team may
have deprived him of his
resting periods and causing
him to feel fatigue and
noting that the client has
low hemoglo&in and
hematocrit count which are
essentials in carrying
oxygen to the &ody.
'ursing intervention aimed
in maximi%ing resting times
of the patient must &e
rendered and at the same
time letting the patient cope
with his recovery phase.
a"tivities at
level of ability
/arti"i/ate in
re"ommende
d treatment
/rogram
S- Doenges et. al. 3454
*re'en&i'e(
I- /erform interventions in bet.een
rest /eriods
,- to /revent fatigue
S - Doenges et. al. 3454
I- instru"t "lient on met%ods to
lessen eJort in doing (DAs
,- to "onserve energy
S- Doenges et. al. 3454
S;C8ND(,H IND;,V;NDI8NS
C"ra&i'e
I-assist in administration of
medi"ations
,- to /romote faster re"overy from
"ondition
S- Doenges et. al. 3454
D;,DI(,H IND;,V;NDI8NS
Re-a#ili&a&i'e
I- en"ourage "lient to rest in free
times
,- to /rovide energy to body
S- Doenges et. al. 3454
I- en"ourage "lient to /arti"i/ate in
(DAs in t%e least minimum
,- to /romote "oo/eration and
inde/enden"e
S- Doenges et. al. 3454
.i#liograp-/(
Doenges0 !E0 !oor-o"se !10 2 !"rr AC0 N"rse3s *o%4e& G"ide( Diagnoses0 *riori&i5ed
In&er'en&ions and Ra&ionales0 +2
&-
edi&ion0 16A6 Da'is3 Compan/0 *-iladelp-ia *enns/l'ania0 20+0